Vision Outcomes in Early vs Late Surgical Intervention of Pituitary Apoplexy: A Meta-analysis

Background: Pituitary apoplexy (PA) commonly manifests as a sudden headache accompanied by neuro-ophthalmic deficits due to hemorrhage or infarction of a preexisting pituitary adenoma. PA can be managed either conservatively or with surgical decompression. At present, the UK Guidelines on PA management recommend that if surgical intervention is to be performed, it should be within the first 7 days following apoplexy (Rajasekaran et al 2011). Despite this recommendation, no meta-analysis has been conducted on whether or not surgical intervention before or after 7 days influences postoperative visual outcomes.

Methods: A thorough literature search of the published English-language literature was performed in PubMed, Ovid, and Cochrane databases using the keywords “pituitary apoplexy” and “surgery” or “vision.” A total of 234 papers published in the past 20 years were found and reviewed. Patient demographics, number of PA patients, visual acuity/field deficits, the presence of ophthalmoplegia, and mean time in days from apoplexy to surgery (ATS) data were extracted. The primary outcome variable evaluated using a binary random-effects model was vision recovery outcomes (metric: odds ratio).

Results: After careful review of the published articles, 14 papers reported data on vision outcomes following surgical intervention in PA patients before or after 7 days were included in the analysis containing 250 patients (mean age = 47.2; M:F = 2.7:1) studied during 1998–2018 ([Fig. 1]). A total of 89% of PA patients presented with a visual deficit (ATS < 7 days in 155 patients, and > 7 days in 95 patients). In patients with an ATS of < 7 days, 91.6% experienced visual recovery, while 90.5% of patients with an ATS > 7 days experienced visual recovery (odds ratio: 2.1 [95% CI: 0.78–5.60]; p-value = 0.138) ([Fig. 2]).

Conclusion: This meta-analysis is the first to compare neuroophthalmic outcomes following surgery for PA decompression based on early versus late intervention. Despite the recommendation of prompt surgery, ATS varied among institutions. Recovery of neuroophthalmic deficits was greater than 90% for patients in both the early and late intervention groups. Because there was no significant difference in vision recovery based on ATS, conservative management may be warranted for early stabilization prior to surgical intervention in PA patients. Nonetheless, further investigation into short- and long-term visual and nonvisual clinical outcomes following surgical intervention in PA based on intervention timing is warranted.

Fig. 1 Flow diagram of study selection.

Fig. 2 Forest plot demonstrating an odds ratio of 2.1 (95% CI: 0.78–5.60), p = 0.138, for studies in which the surgical intervention for PA was performed less than or greater than 7 days.

No conflict of interest has been declared by the author(s).